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# UNCLASSIFIED/Maxico CitySTATEMENT OF PRIOR FEDERAL CIVILIAN AND MILITARY SERVICEAND DETERMINATION OF COMPETITIVE STATUSIMPORTANT: The information on this form will be used (1) in determining creditable service for leave purposes and retention credits for reduction in force, and (2) in determining agency determination of competitive status. The employee should complete Part I and the Personnel Office should complete Parts II through V.PART I-EMPLOYEE'S STATEMENT1. NAME (Last, first, middle initial)SHAW, Robert T.2. DATE OF BIRTH6-18-25PART II-THIS COLUMN IS FOR PERSONNEL OFFICE USE9. RETENTION GROUP3. LIST THE FOLLOWING INFORMATION CONCERNING ALL FEDERAL AND DISTRICT OF COLUMBIA SERVICE YOU HAVE HAD PRIOR TO YOUR PRESENT APPOINTMENT (Do not include military service.)10. A. CSC STATUS YES NOB. TYPE OF PRESENT APPOINTMENT| NAME AND LOCATION OF AGENCY | FROM |       |     | TO   |       |     |                                 || --------------------------- | ---- | ----- | --- | ---- | ----- | --- | ------------------------------- ||                             | YEAR | MONTH | DAY | YEAR | MONTH | DAY | TYPE OF APPOINTMENT & AUTHORITY || FOREIGN SERVICE             | 49   | 10    |     | 52   | 2     |     |                                 || DEPT OF STATE               |      |       |     |      |       |     |                                 || DEPT OF DEFENSE             | 52   | 5     |     | 54   | 7     |     |                                 || DEPT OF DEFENSE             | 54   | 7     |     | 56   | 6     |     |                                 || FOREIGN SERVICE             | 56   | 6     |     | 61   | 5     |     |                                 || DEPT OF STATE               | 61   | 5     |     | 63   | 3     |     |                                 |4. LIST PERIODS OF ACTIVE SERVICE IN ANY BRANCH OF THE ARMED FORCES OF THE UNITED STATES. IF YOU HAD NO ACTIVE MILITARY SERVICE, WRITE NONE.| BRANCH | FROM |       |     | TO   |       |     | DISCHARGE (None or dishon P) || ------ | ---- | ----- | --- | ---- | ----- | --- | ---------------------------- ||        | YEAR | MONTH | DAY | YEAR | MONTH | DAY |                              || ARMY   | 43   | 9     | 11  | 45   | 3     | 8   | HON.                         |11. SERVICE| YEAR | MONTH |     || ---- | ----- | --- ||      |       |     |5. DURING PERIODS OF EMPLOYMENT SHOWN IN ITEM 3, DID YOU HAVE A TOTAL OF MORE THAN 5 MONTHS ABSENCE WITHOUT PAY, INCLUDING PERIODS OF MERCHANT MARINE SERVICE, DURING ANY ONE CALENDAR YEAR? YES NO   IF ANSWER IS "YES," LIST FOLLOWING INFORMATION.12. TOTAL SERVICE| TYPE IF KNOWN (LWOP, Furl, Susp, AWOL, Mor Mar) | FROM |       |     | TO   |       |     | TOTAL  |      || ----------------------------------------------- | ---- | ----- | --- | ---- | ----- | --- | ------ | ---- ||                                                 | YEAR | MONTH | DAY | YEAR | MONTH | DAY | MONTHS | DAYS ||                                                 |      |       |     |      |       |     |        |      |13. NONCREDITABLE SERVICE (Leave purposes only)6. DURING THE FEDERAL SERVICE LISTED IN ITEM 3. DID YOU ACQUIRE A PERMANENT COMPETITIVE CIVIL SERVICE STATUS?   YES NO14. NONCREDITABLE SERVICE (RIF purposes only)15. UNEMPLOYMENT RIGHTS16. THE WIDOW OF A DECEASED VETERAN? YES NO17. ELIGIBILITY FOR LISTING ON RE-EMPLOYMENT PRIORITY LIST18. THE WIFE OF A DISABLED VETERAN? YES NO19. THE UNREMARRIED WIDOW OF A VETERAN? YES NO20. TO BE EXECUTED BEFORE A NOTARY PUBLIC OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHSI swear (or affirm) that the above statements are true to the best of my knowledge and belief.Robert ShawDOD 3-27-63Washington D. C.Subscribed and sworn to before me on this 27th day of March 1963, at Washington.Ronald C. SmithNOTE: If oath is taken before a Notary Public, the date the commission expires should be shown; if taken before a Department of the Government, the title of the officer should be shown.INSTRUCTIONS: This form is to be prepared outside of the employee's official personnel folder immediately before or after the personnel action is effected.(OVER)